Avenues at Quad Cities

Inspectors wroteBased on interview and record review the Facility failed to obtain Facility Initiated Discharge Physician Orders, follow current Discharge Care Plans, provide written 30 Day Notice of Discharges to resident's/resident's responsible party, document discharge planning and resident specific needs/services, and document sufficient preparation/orientation to residents to ensure safe/orderly transfers/discharges from the facility for 13 of 14 residents (R1, R2, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13 and R14) reviewed for Facility Initiated Discharges in a sample of 14. These failures resulted in residents suffering psychosocial harm as any reasonable person would experience after being displaced from their home and moved further away from family and friends and R5 verbalizing feelings of anxiety, sadness and anger.

Inspectors wroteBased on record review and interview the Facility failed to notify Resident/Resident's Representatives of transfers/discharges and the reasons for the move in writing at least 30 days prior to transfer discharge, send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman, record the reasons for the transfer/discharge in the Resident's medical record or provide a statement of the resident's appeal rights for 12 of 14 Residents (R2, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13 and R14) reviewed for Facility Initiated Discharges in a sample of 18. These failures resulted in residents suffering psychosocial harm as any reasonable person would experience after being displaced from their home and moved further away from family and friends and R5 verbalizing feelings of anxiety, sadness and anger.

Inspectors wroteBased on interview, observation and record review, the facility failed to provide supervision to a wandering resident with a known mental health history and previous elopement, conduct an assessment and investigation to determine risk of elopement, develop a care plan addressing elopement risk, and ensure the physician was notified of a resident elopement for one of three residents (R1) reviewed for elopement in the sample of three. These failures resulted in R1, a resident with a known history of multiple psychiatric issues, eloping from the facility at night during freezing temperatures, without staff knowledge, and was later found wandering over a half of a mile from the facility, near a busy highway, with urine saturated pants, confusion, and agitation. These failures resulted in an Immediate Jeopardy. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to have sufficient staff available to provide nursing services to meet the residents' need in the facility. This has the potential to affect all 31 residents currently residing in the facility.

Inspectors wroteBased on interview and record review the facility failed to include the Infection Preventionist position or duties in the Facility Assessment. This failure has the potential to affect all 31 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to develop, implement, and maintain documentation; and demonstrate evidence of its ongoing QAPI/Quality Assurance Performance Improvement program. This has the potential to affect all 31 residents currently residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement plans of action to make improvements to residents' quality of care and quality of life in its QAPI/Quality Assurance Performance Improvement program. This has the potential to affect all 31 residents currently residing in the facility.

Inspectors wroteBased on interview and record review the facility failed to implement an ongoing infection prevention and control program (IPCP), failed to include an ongoing system of surveillance, and failed to implement a program to manage and minimize the risk of waterborne pathogens. This failure has the potential to affect all 31 residents.

Inspectors wroteBased on interview and record review the facility failed to develop and implement an ongoing facility-wide system to monitor the use of antibiotics and failed to include leadership support and accountability via the participation of an individual with designated responsibility for the infection control program (i.e., Infection Preventionist). These failures have the potential to affect all 31 residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to employ a Certified Infection Preventionist. This failure has the potential to affect all 31 residents in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure documentation in the resident's medical record of the administration or refusal of the Influenza and/or Pneumococcal vaccinations for three residents (R17, R26, R29) of five residents reviewed for Influenza and Pneumonia vaccinations in the sample of 21. The facility also failed to provide surveillance monitoring and tracking of immunizations for residents. This failure has the potential to affect all 31 residents.

Inspectors wroteBased on interview and record review the facility failed to provide a surveillance system to identify possible communicable disease or infections, how and when to use Transmission Based Precautions and proper infection and prevention and control practices when performing resident care activities. This failure has the potential to affect all 31 residents.

Inspectors wroteBased on record review and interview, the facility failed to provide a copy of the bed hold policy for the resident discharging to the hospital for one of one resident (R6) reviewed for bed hold in a sample of 21. Findings Include: The facility policy named, Bed Hold Guarantee Policy, dated 8/1/2017, documents the following. The resident, resident family or legal representative will be given the appropriate Notice of Bed Hold Policy at the time of discharge or therapeutic leave, if possible, but notice will be given no longer than 24 hours after discharge or initiation of leave. R6's Short Transfer Form from a local hospital, dated 9/6/2024, documents R6 was seen in the emergency room for a diagnosis of End of Life care. [...]

Inspectors wroteBased on record review and interview, the facility failed to obtain a new level one PASRR (Pre-admission Screening and Resident Review) for 2 of 3 residents (R13 and R25) reviewed for pre-admission screenings in the sample of 21. Findings Include: The facility policy named, Resident Assessment- Coordination with PASRR Program, no date, documents, If a resident who stays in the facility longer than 30days: a. The facility must screen the individual using the State's Level I screening process and refer any resident who has or may have a mental illness or intellectual disability to the appropriate state designated authority. The Social Service Director shall be responsible for keeping track of each resident's PASRR screening status and referring to the appropriate authority. 1. R25's Interagency Certification of Screening Results, dated 10/29/2020, documents the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify the physician and initiate treatment for a skin fold wound for one resident (R20) of one resident reviewed for skin impairments in the sample of 21.

Inspectors wroteBased on interview and record review, the facility failed to maintain and process pharmacist drug regimen review recommendations for one (R24) of 12 residents reviewed for drug regimen review in a sample of 21.

Inspectors wroteBased on record review and interview, the facility failed to provide a resident and resident's representative with a written notice of transfer (R6) and the facility failed to notify the facility Ombudsman monthly of resident transfers to the hospital. This failure has the potential to affect all 31 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician of a diabetic resident receiving a nutritionally- inadequate clear liquid diet tray for most meals or not eating at all during the span of five days, while continuing to receive the ordered oral and injectable diabetic medications. This failure resulted in R1 being hospitalized for Hypoglycemia and Altered Mental status.

Inspectors wroteBased on observation, interview and record review, the facility failed to allow a resident the right to exercise the choice to eat meals in bed, for two of three residents (R1, R2), reviewed for resident rights, in a sample of three.

Inspectors wroteBased on interview and record review, the facility failed to provide a resident with a nourishing, well balanced diet for one of three residents (R1), reviewed for nutrition, in a sample of three.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop resident care plans for three (R1, R14, and R17) of 12 residents reviewed for care planning in a total sample of 19.

Inspectors wroteBased on interview and record review, the facility failed to provide the services of a Registered Nurse eight hours a day, seven days a week. This failure has the potential to affect all 29 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to perform the required twice weekly COVID-19 testing on staff members who are currently not up to date with the COVID-19 vaccination. This failure has the potential to affect all 29 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure all staff members were fully vaccinated for COVID-19. This failure has the potential to affect all 29 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to place a resident in the required transmission-based precautions. This failure has the potential to affect four of four residents (R13, R25, R128 and R129), reviewed for infection control in a sample of 19. The facility policy, Multi-Drug-Resistant Organisms in Non-Hospital Healthcare Setting, dated (reviewed 4/11/22) directs staff, multi-resistant drug organisms are bacteria and other microorganisms that have developed resistance to antimicrobial drugs. Common examples of these organisms include: ESBL (Extended Spectrum Beta Lactamase). Risk factors for development (of ESBL) include underlying diseases or conditions, particularly Chronic Renal Disease. In addition to Standard and Contact Precautions, place the resident in a private room. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure policies and procedures regarding hand hygiene were followed during pressure ulcer care for one of one residents (R21) reviewed for pressure wounds, in a sample of 19.

Inspectors wroteBased on observation, interview and record review, the facility failed to reconcile controlled medications for one of 13 residents (R21) reviewed for medications in the sample of 19.